Physical Therapists' Perceptions of Leadership across the Health Care Continuum: A Brief Report

ABSTRACT

Purpose: To describe and compare Canadian physical therapists' perspectives on the importance of characteristics required for leadership in the workplace and in society and to explore the implications for the profession. Methods: This quantitative, cross-sectional study used a web-based survey of members of the Canadian Physiotherapy Association (CPA) with a registered email address (n=6156). The perceived importance of leadership characteristics at the workplace level versus the societal level was examined using a Mann-Whitney U test, with the significance set at α=0.05. Results: A total of 1,511 respondents completed the questionnaire for a 24.5% response rate; they rated communication, professionalism, and credibility as the most important characteristics. For each of the 15 leadership characteristics, significantly fewer physical therapists chose the rating “extremely important” at the societal level than did so at the workplace level (p<0.001 for all characteristics). Conclusions: Physical therapists consistently rate leadership characteristics as more important in the workplace than at the societal level. Future research should aim to guide understanding about the reasons for this difference in perceived importance of leadership characteristics across different contexts.

Over the past 5 years, the economy has witnessed a decline in revenue growth and an increase in unemployment rates, resulting in the current climate of fiscal conservatism. Increased scrutiny of public spending spurred thorough reviews of government spending, resulting in continued fiscal restraints on health care systems. Across Canada, there has been a degree of change sweeping through the provincial health care systems that is increasing expectations of scope of practice and competency of health care professionals.^1–3 The Drummond report was commissioned by the government of Ontario to address the fiscal reform of the province's public services. This report, released in 2012, recommended shifting toward a patient-centred system in which “funding to providers should be based primarily on meeting the needs of patients as they move through the health care continuum.”^2(p.174) It reflects the reality that a growing demand for effective, evidence-based care is at the forefront of health care policy as the provision of health services becomes increasingly competitive.² The evolution of this health care reform requires professional leaders and advocates who will increase the profile of their respective professions while addressing the changes necessary for a sustainable professional future in the new health service environment. Health care organizations around the world are responding to this new environment by exploring both formal leadership training⁴ and informal leadership roles and practices distributed throughout the health care system in order to advance innovative health care practices.⁵ Leaders in health care are individuals who influence the actions of other individuals or groups toward accomplishing goals and who set the pace and direction of change while facilitating innovative practice.⁵ As the profession further develops emerging roles such as advanced practitioners and clinical specialists, physical therapists need to understand and establish the profession's perception of leadership to achieve professional growth within the health care system.

As a profession, physical therapists are in a unique position of receiving both public and private funding, depending on the area and focus of practice. Like all health professions, physical therapy is financially susceptible to decisions made by clients, institutions, and government funding agencies. A nuanced understanding of systemic infrastructures as they relate to funding and provision of care is essential to the professional growth of physical therapists, as advocacy efforts tailored to each of these groups are key to sustainability. Health care providers who enter into managerial and administrative roles have the opportunity to add value to the delivery of patient-centred services in complex health care systems, elevating their profession as a result.

Our earlier study⁶ was the first to address physical therapists' perceptions of the characteristics required for leadership in health care. It provided a foundation for discussing leadership in physical therapy and the importance of leadership with respect to the profession's position in Canadian health care systems.⁶ One essential component of effective leadership is advocacy, which, according to the National Association of Healthcare Advocacy Consultants (NAHAC), “enables clients and client communities to actualize choices and access resources.”⁷ The Essential Competency Profile for Physiotherapists in Canada defines an advocate as one who “responsibly uses his or her knowledge and expertise to promote the health and wellbeing of individual clients, communities, populations, and the profession.”^1(p.5) One of the enabling competencies is using “opportunities to communicate the role and benefits of physical therapy to enhance individual and community health including health promotion and disease prevention,”^1(p.12) that is, to optimize function for the clients we serve. This competency directly reflects the advocacy role described by the NAHAC.

Overall effectiveness of the health care system is improved by augmenting detailed knowledge of funding structures and operations with clinical knowledge. Physical therapists are well equipped with clinical knowledge through their education and continuing professional development, governed by rigorous accreditation processes and the breadth and depth of their individual clinical experience. We can maximize our influence within the health care system by effectively communicating how our profession can help to transform health care. Determining the profession's readiness to assist and lead in this transformation agenda requires an understanding of the perception of leadership at multiple levels. This study, therefore, undertook a secondary analysis of previously collected data⁶ to investigate Canadian physical therapists' perceptions of leadership attributes required in the workplace and at the societal level.

Methods

This quantitative, cross-sectional study was completed using a Web-based questionnaire distributed by email using a modified Dillman method.⁸ The survey link was sent to registered members of the Canadian Physiotherapy Association (CPA); data were collected over 5 weeks, between January and March 2011. The study design and initial statistical analyses have been reported elsewhere.⁶ Briefly, we developed a 24-item questionnaire that captured demographic information (including level of education, workplace setting, and area of practice) and asked participants to rate the perceived importance of 15 leadership characteristics across three settings: within their immediate workplace setting, within the health care system as a whole, and at a broader societal level (see Appendix). These 15 characteristics were chosen from the literature based on being consistently identified as important in both business and health care settings. For the present study, we conducted a secondary data analysis comparing the perceived importance of these characteristics in the workplace and at the societal level. We hypothesized that a difference would exist between the perceived importance of leadership characteristics at these two levels. Data were analyzed using the Mann-Whitney U test, with significance set at α=0.05.

Results

Of the 6,156 CPA members who were e-mailed the survey link, 1,511 completed the survey for a response rate of 24.5%. Of these respondents, 84.1% were female; 43.8% respondents reported working in the public sector, 38.8% in private practice, 11.4% in other types of facilities, and 6.0% in an educational institution. Communication, professionalism, and credibility were perceived to be the most important leadership characteristics across all three settings (workplace, health system, society).

Perceived importance of characteristics in the workplace versus society

Data were grouped and reported according to the characteristics that respondents perceived as “extremely important” and “important”. Table 1 summarizes the perceived importance of leadership characteristics to physical therapists pertaining to the workplace and societal settings. All 15 characteristics were perceived as “extremely important” or “important” by significantly fewer respondents in society than in the workplace (p <0.001).

Table 1.

Percentage of Respondents who Rated Leadership Characteristics as “Extremely Important” or “Important” in the Workplace and Society Settings

	% physical therapists perceiving as important or extremely important
Characteristic*	Workplace	Society
Communication	75.1	50.9
Professionalism	65.0	50.6
Credibility	58.9	37.2
Active management	58.9	25.7
Ability to motivate	58.7	25.8
Self-regulation	56.2	29.6
Contingent reward	53.3	27.5
Social skills	53.1	29.3
Empathy	39.5	25.6
Ability to delegate	36.5	13.8
Vision	35.5	33.6
Self-awareness	25.2	17.9
Extroversion	22.3	15.9
Business acumen	22.0	16.0
Social dominance	20.2	16.5

^*All statistically significant at p<0.001.

Discussion

This is the first study to link physical therapists' perceptions of leadership characteristics across health care environments to the impact of these perceptions on professional growth as leaders in health care. With a variety of internal and external stakeholders influencing health care, perceptions of leadership are just as important as actual leadership qualities.⁹ The top three characteristics physical therapists identified as important are incongruent with those reported in the physician and nursing literature.^5,10,11 Our findings help to characterize the profession and to describe which leadership attributes physical therapists value at a societal level and the extent to which they value these characteristics. The data also reveals that physical therapists are less likely to perceive leadership characteristics as important or extremely important at a societal level than in their immediate workplace setting. This may reflect the demographics of the study sample, as the majority of respondents reported working in a clinical care environment. However, this explanation does not extend to other health care professions: the attitudes of physicians reflect an appreciation for leadership beyond the clinical environment, recognizing the impact of their skills as both clinicians and leaders in the health care system.¹²

Although our findings are open to a variety of potential interpretations, the decrease in perceived importance of leadership attributes at the societal level may reflect the current mindset of physical therapists: they are more focused on the concept of leadership in their immediate workplace environment than in societal settings. Our findings may also indicate that physical therapists are united in their perception of leadership in the workplace but have difficulty in extending these perceptions beyond their immediate work setting. This difficulty is not unique to physical therapists: at the 2011 Canadian Medical Association annual meeting, 95% of delegates voted to “facilitate the incorporation of increased formal training in the techniques of advocacy and leadership in the undergraduate and postgraduate medical curricula.”¹³ Physical therapists, alongside their health care colleagues, are well positioned to move the profession forward in these respects and to strengthen their impact on the system. However, to achieve this professional “growth,” physical therapists will need to recognize leadership roles and opportunities for advocacy beyond their immediate work environment.

The data suggest that as a whole, the profession, in its current environment of health care reform, will need to focus more diligently on opportunities at a systemic and societal level to maximize its profile and contribution to all levels within the health system. Our findings indicate that professional self-awareness is the first step toward understanding what the profession as a whole values. They challenge physical therapists to reflect on the current state of the profession and the direction it must take in the future to demonstrate how physiotherapy adds value to the health care system at a patient, program, or system level. As a patient-centred health profession, external validation surrounding quality of care enables physical therapists the capacity to serve health care system reform. To raise the profile of our profession, we must use our leadership capacity to advocate effectively in all leadership positions, communicating the value of physical therapy to the success of the health care system.

Pursuing managerial and executive positions within health care institutions and private companies keeps our professional agenda at the forefront of strategic decisions. On a societal scale, leadership opportunities exist along a continuum from provincial and national advocacy efforts to political engagement. We recommend that the national and provincial physical therapy associations, the university physical therapy educational programs, the National Physiotherapy Advisory Group, and the provincial regulatory bodies address the development of leadership capacity for health care system reform in innovative and meaningful ways.

The limitations of this study, as described elsewhere,⁶ relate to the study design and bias associated with administering a web-based survey. Some of the terms used in the survey may have been unclear, leading to differences in interpretation among respondents. This possibility was mitigated by including operational definitions of key terms to establish consistency. The method of delivery allowed for a higher absolute response rate than previous comparable electronic surveys of Canadian physical therapists.^14,15 The demographic profile of the total respondent sample was compared to the demographic profile of all registered Canadian physical therapists and determined to be an accurate demographic sampling of the population,⁴ indicating that the results have some degree of generalizability.

Conclusion

Physical therapists in Canada perceive leadership characteristics to attenuate in importance as they move away from the workplace setting. If we are to increase the profile of the profession and inspire professional growth within the changing health care climate, the importance of leadership characteristics must be appreciated at multiple levels within the system. Our medical colleagues have recognized the importance of multi-faceted leadership in health care and are strengthening the focus on leadership and advocacy within their profession. Other health professionals must respond to this shift and recognize its importance for success in an evolving health care system. Recent changes in and dialogue around health care delivery at national and provincial levels has energized the public's desire to address health care issues. Patients are ready to speak out about the reforms they desire, and the physical therapy profession must be ready to listen to and engage in that dialogue, both with patients and at a systemic level.

Key messages

What is already known on this topic

No study to date has used quantitative results to promote self-awareness and inform about the advocacy efforts of physical therapists. The literature demonstrates that other health professions are increasingly self-aware, recognizing the importance of the advocacy role within a broader leadership framework as well as its implications for a unified profession and successful positioning within the health system.

What this study adds

This study compares the importance of 15 leadership characteristics across different health care contexts from the perspective of physical therapists in Canada, linking the results to professional growth and to our position within the health care system. The study relates our essential competencies, specifically the concept of advocacy, to the broader scope of professional leadership. Understanding our perspectives and the broader application of core competencies is integral to professional growth and also to our ability to move forward as a profession. Most importantly, this report presents a unified approach to initiating a shift in leadership efforts that may positively influence the profile of physical therapy at a societal level.

APPENDIX: Survey excerpt

The following questions ask about your perceptions of the importance of specific leadership characteristics in various contexts. For the purposes of this study, the following operational definitions have been established:

1. A leader is defined as an individual who influences the actions of another individual or group toward accomplishing goals and sets the pace and direction of change while facilitating innovative practice.

2. Workplace setting refers to your primary work environment.

3. Health care system refers to the level of hospital administration and networks that govern the overall operation of health care.

4. Society refers to the global environment in which the community functions.

For the following items, please place a mark in the appropriate box that indicates your response.

9. Credibility—up to date on continuing education; able to give guidance or directions to find answers or solutions

a) workplace setting	□1 Not at all important	□2 Not very important	□3 Neutral	□4 Very important	□5 Extremely important
b) health care system	□1 Not at all important	□2 Not very important	□3 Neutral	□4 Very important	□5 Extremely important
c) society	□1 Not at all important	□2 Not very important	□3 Neutral	□4 Very important	□5 Extremely important

Physiotherapy Canada 2014; 66(2);119–123; doi:10.3138/ptc.2013-02